Patient Safety Policy and Procedure Team Update Team Members - - PowerPoint PPT Presentation

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Dec 09, 2022 364 likes •466 views

Just Culture: Accountability for Patient Safety Policy and Procedure Team Update Team Members Lisa Bonacci (co-chair), Vice President, HR Services and Operations Joanne Sorensen (co-chair), Director, Care and Quality Management

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Policy and Procedure Team Update

Just Culture: Accountability for Patient Safety

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Lisa Bonacci (co-chair), Vice President, HR Services and Operations
Joanne Sorensen (co-chair), Director, Care and Quality Management
Chris Cepullio, Patient Safety Coordinator
Linda Conroy, Director, Accreditation & Regulatory Compliance
Glenda Davis, Director, PCS Administration
Mark Frick, Vice President, Human Resources
Tony Gigliotti, Program Director, Talent Management
Lisa Painter, Director, Risk Management
Chaton Turner, Assistant Counsel

Team Members

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Create an algorithm that provides:

– a structured process to guide managers through the evaluation of an event or near miss; – an outline for conducting an investigation of an event by posing critical questions; – a decision tree for identifying system failures and human errors; and – a tool for assessing accountability (remedial, punitive, etc.) for those involved in an event.

Ensure that key UPMC policies support the Just Culture

philosophy. Team Objectives

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Duty to produce an outcome

– Applies when an individual knows the desired outcome and should be able to produce it (e.g. the safe removal of an appendix or urinary catheter)

Duty to follow a procedural rule

– Applies when an individual knows the proper procedure and it is possible to follow the rule

Duty to avoid causing unjustifiable risk or harm

– Breach of this duty occurs when an individual intentionally harms the patient or acts recklessly

Reference: California Hospital Patient Safety Authority, (2010) Accessed January 20, 2011 @ http://www.chso.org/just/index.asp

Our Duties

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Four key questions guide investigation of an event:

– Were the actions as intended? – Does there appear to be evidence of ill health or substance abuse? – Did the individual depart from agreed protocols and/or safe procedures? – Would another individual coming from the same professional group (within or outside UPMC), possessing comparable qualifications and experience, behave in the same way in similar circumstances?

UPMC Just Culture Algorithm: Key Questions

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UPMC Just Culture Algorithm: Outcomes

Type of Behavior Behavioral Definition Possible Outcomes Malicious behavior Harm was intentional. Corrective action (including discharge), legal proceedings Unfit for duty Performance is impaired by illegal or legal substances; cognitive or physical impairments; other health issues; and/or severe psychological stressors. Fitness for Duty Policy Reckless action Rules are knowingly violated, and/or a dangerous/unsafe decision was made. Corrective action, retraining, teaching others Risky action Potentially unsafe choice was made. Coaching, teaching others, corrective action (for repeated issues) Individual human error or system failure Human error was made, and/or system infrastructure increased chances of error. Consoling, fixing system issues, communicating to staff, retraining, coaching

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DRAFT

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Corrective Action and Discharge Policy
Performance Management Policy
UPMC Code of Conduct
UPMC Patient Safety Plans

Under Review

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